What Is Pharmaceutical Care

Published Date: 02 Nov 2017

Pharmaceutical care is a core area in the pharmacy practice which involves mainly:

Understanding and analyzing the patient medication and disease history.

Accessing and analyzing the patient symptomatic and diagnostic profile.

Efforts to minimize the patient symptoms by developing specific goals.

Satisfying the patient medication needs.

Giving the appropriate advices and education both on the pharmacological and non pharmacological aspects.

Solving the patient complains about medications and increase pharmacological adherence.

Counseling the patient on various factors and educates them.

http://t3.gstatic.com/images?q=tbn:ANd9GcS90sf9AU8O6ech0OVt-5TO9b7rXyTS8nmftuD6ju_E3WR6k_X4

In this case of Hafsana , we will follow the basic pharmaceutical plan along with any relevant material and information to established the strong disease management which proves to be useful for her. For this we will follow the step wise approach, starting with symptoms and try to rule out any other possible causes for her conditions so that the perfection can be achieved in this whole pharmaceutical care process.

SYMPTOMS

HAFSANA SYMPTOMATIC PROFILE SHOWS:

Mouth ulcers

Amenorrhea

Pale skin(Anemia)

Osteoporosis

While the most common symptoms for the celiac diseases in majority of peaople are:

http://www.uspharmacist.com/CMSImagesContent/2011/12/_USP1112-Celiac-T1.gif

All of the above mentioned symptoms are quite common in patient of her age with celiac disease but it cannot exclude the other causes which can logically be considered here.

LOGICAL CONSIDERATIONS

All of the symptoms she presents are quite common in patient of her age with celiac disease but it cannot exclude the other conditions like crohon disease, lactose intolerance, allergies, ulcerative colitis , Irritable bowl syndrome , parasitic infections or thyroid dysfunction.

The amenorrhea may or may not linked up with the celiac disease.

Celiac disease is not always present itself with symptoms.

Osteoporosis is also linked up with:

Corticosteroids use

Medications such as anticonvulsants, proton pump inhibitors.

Hypogonadism

Thyroid dysfunction

Amenorrhea is also linked up with:

Intense exercise

Birth control pills

Pregnancy

Hyperthyroidism

Pituitary disease

We can also check her for any skin rashes in the torso and scalp areas which is a common and differential symptom for celiac disease ,a condition called as dermatitis herpetiforms.

As celiac disease is an autoimmune condition so the patient can be cross questioned for any other autoimmune conditions like type 1 diabetes, Cushing syndrome and myasthenia gravis..

Do ask for her about any family member who is presented with such symptoms as the celiac disease has a link with genetics.

Also studies shows that it is more common in women.

Patients with celiac disease have also been found to have an increased risk of developing certain infectious diseases that include pneumococcal or staphylococcal sepsis and tuberculosis

COMMENTS

By seeing her symptomatic profile it is probable that she is a patient of celiac disease with moderate anameia( according to WHO scale).

Also studies shows that CELIAC DISEASE is more common in women.

BLOOD PROFILE

After establishing the relevance between the symptoms and diagnosis for the Hafsana we may proceed with the serological tests performed on her.

HAFSANA BLOOD TEST FINDINGS ARE:

Anti-gliadin antibodies test (AGA)………………positive

Hb test (8.8mg/dl)………………………………..Anemia

Folate test………………………………………..Low levels

Iron test…………………………………………..Low levels

All of the results from the serological tests here show reasonable clue for the celiac disease with the most important test being the detection of AGA test but few logical questions arise here.

LOGICAL CONSIDERATIONS

Has Hafsana tested for pregnancy, FSH and Estrogen to show whether her secondary amenorrhea has a relation to pregnancy or other hormonal imbalances .

Had she engaged with other causes of amenorrhea like heavy exercises, contraceptive pills.

If such tests are covered in her gynecological examination and that the results are normal than her amenorrhea definitely has a linkage with the celiac disease. The literature also support the association between amenorrhea and celiac disease. This is mainly due to mal absorption of magnesium. Selenium, zinc and iron whose shortage disturbs the hormonal production and thus woman experience the amenorrhea, early menopause and bleeding.

The antibody detection tests used in celiac disease are basically of 3 with most specific and sensitive being an IgA tissue transglutaminase (tTGA) test .Why she has not tested with this.

Is she detected for IgA deficiency .If yes then must be tested for EMA IgG test

Has all the tests follow in CPD labs.

Was she on gluten free diet before testing because it is necessary to be on gluten containing diet before testing. It is recommended that you eat some gluten at least one meal every day for at least six weeks before testing.

Had she tested for hyperthyroidism as it is connected to celiac disease.

These all considerations should be met for further endoscopic investigations as endoscopy is considered as gold standard whether or not the blodd tests are positive.

COMMENTS

All of the results from the serological tests here show reasonable clue for the celiac disease with the most important test being the detection of AGA antibodies.

HISTOLOGICAL EXAMINATION

HASANA ENDOSCOPIC EXAMINATION RESULTS SHOWS:

VILLOUS ATROPHY

Marsh classification is used in which following changes occurs as the celiac disease progresses within small intestine:

Increased intraepithelial lymphocytes.

Change from columnar to cuboid cells.

lamina propria cellular infiltration,

Crypt elongation and hyperplasia,

increased crypt mitotic index, and progressive villous flattening or blunting.

As a whole this is described as a "cracked-mud" appearance,

http://2.bp.blogspot.com/_zIDF7N81bbQ/S9Dte7QMstI/AAAAAAAAASI/P6Yt6D_wA6w/s1600/MARSH.jpg

Marsh classification for the celiac disease

http://upload.wikimedia.org/wikipedia/commons/thumb/d/d6/Celiac_endo.JPG/220px-Celiac_endo.JPG

Villous atrophy Crack mud appearance

As far as the serology and histological findings are considered ,Hafsana Clearly is a patient of celiac disease but few considerations can be put into the context:

LOGICAL CONSIDERATIONS:

Villous atrophy can also be found in other conditions like crohon disease, lactose intolerance, tuberculosis and zollinger-ellison syndrome thus these causes can not be excluded.

Sometimes false histological findings are achieved for example an isolated increase in intraepithelial lymphocytes in the absence of villous atrophy may exist , in such cases repeat biopsy in the context of celiac serology, symptoms is needed.

If diagnostic doubt persists then biopsy after a gluten-free diet and possibly gluten challenge can be performed.

COMMENTS

Although Hafsana biopsy findings confirmed that she is a patient of celiac disease but a definitive diagnosis can only be made her symptoms clearly improve while maintaining the special diet which is gluten-free diet.

MANAGEMENT

Hafsana is newly diagnosed with celiac disease and now is ready to be on management stage for her disease , also she has never been treated before for this condition thus a special care has to be taken for her .

Basic principal for management:

 CELIAC:

Consultation with dietician,

Education about the disease, 

Lifelong sticking a gluten-free diet, 

Identification and treatment of nutritional deficiencies

Access to an supportive group,

Continuous long-term follow-up .

Desired Outcome:

Overall goals of treatment for her include :

Relieving her symptoms.

Curing the intestine while reversing the effects of mal absorption.

Enabling Hafsana to adhere to a healthy, interesting, and practical gluten-free diet.

NON PHARMACOLOGICAL MANAGEMENT

HAFSANA MAIN CONCERN IS TO HAVE GLUTEN FREE LIFE FOR WHICH SHE HAS TO FOLLOW THE FOLLOWING THINGS

ONLY GLUTEN FREE PRODUCTS

GLUTEN FREE FOODS

When the food is gluten free?

When a food has less than 20 parts per million(ppm) or 30-50mg/day of gluten in it.

Things she should know:

Strict adherence to the diet allows not only the healing of intestine and thus the symptoms but also eliminate the risk of osteoporosis and intestinal cancer .

Clinical improvement can be observed within days or weeks of consuming gluten free diet.

Ingestion of only certified pure gluten-free oats are safe.

Grains and Other Foods that Do and Do Not Contain Gluten

Contain Gluten

Do not contain Gluten

Wheat/ Wheat germ

Amaranth

Quinoa

Barley

Buckwheat

Rice

Rye

Corn

Sorghum

Gram flour

Flax

Soybeans

Oats 

Millet

Tapioca

Foods to avoid

Bread, breakfast cereals and pasta.

Biscuits, cakes and pastries.

Some sauces, ready meals and some processed foods.

Pizza bases.

Some snacks.

Chips should not be used if cooked in the same oil in which fish is fried.

Beer made from grain containing gluten.

Certified pure gluten-free oats.

Foods she can eat

All fruit and vegetables.

potatoes

maize and rice.

nuts

lentils and pulses.

chicken, red meat, fish, dairy products and eggs.

Processed foods such as ready meals and soups which are made without gluten.

Alcoholic drinks such as cider, wine spirits included in the gluten-free diet.

http://glutenfreedietplan.us/wp-content/uploads/2012/07/gluten-free.jpghttp://upload.wikimedia.org/wikipedia/commons/thumb/9/99/Glutenfreies_Bier.jpg/220px-Glutenfreies_Bier.jpg

http://health.ninemsn.com.au/img/food/veggies.jpg

Some gluten free foods

GLUTEN-FREE NON FOOD PRODUCTS

Gluten-containing topical products may produce the potential for the gluten ingestion if a patient handles food after using such products.

Health and beauty aids such as lip balm, lipstick, etc

Toiletry such as tooth pastes, shampoos, and soaps.

GLUTEN FREE FORMULATIONS

What she should know:

Prescription medications and medications with a product license number are gluten-free.

If a medicine contains wheat starch she should check with your doctor or pharmacist before taking them.

Medication may have gluten in them in terms of inactive ingredients such as

sweeteners, when in the form of wheat- and barley-based syrups

the solvent or vehicle used in a liquid formulation

She should be advised to contact manufacturers to verify the gluten content of their products..

Help her through websites and publications.

www.glutenfreedrugs.com

www.celiaccentral.com,

www.ashp.org/gluten

HOW SHE CAN OBTAIN GLUTEN FREE PRODUCTS

She can receive gluten-free products on prescription.

She can save money through pre-payment certificate (PPC).Patients who have to pay for more than three prescription items in three months, or 14 items in 12 months can buy PPC.

She should be provided by listing of foods, recipes and books that helps her to be on gluten-free diet.

She should know that gluten-free foods are given in a unit value for example

400g bread/rolls/baguettes   = 1 unit

300g breakfast cereal  = 1 -1/2 units.

In case of females these units are added as follows:

female 75+ years

12

breastfeeding

add 4

3rd trimester pregnancy

add 1

high PAL

add 4

http://t3.gstatic.com/images?q=tbn:ANd9GcQUZUizTLVlhVuRMbc9IowU2GPiDnamVEl7DD3hFG043RpPH0sChttp://t2.gstatic.com/images?q=tbn:ANd9GcQNlSL0HSSxCgPnG8PK4VbbowK_DZzDYJVWi7qTIQdERMqEgYwpBA

Some gluten free recipes

ADVICE HER TO CAREFULLY READ THE LABELS FOR THE PRODUCTS

It is important that she read the labels while purchasing the items to check the amount of gluten in them. According to CODEX standards the food is

gluten free if gluten is (20ppm or less)

has very low gluten if gluten is (21-100ppm)

If she has to purchase the wheat starch , use Codex wheat starch

ADVICE FOR HAFSANA IF SHE IS VEGETERIAN

Combining a gluten-free diet with a vegetarian diet can enhance the risk for the nutritional deficiencies, it is therefore very important to plan meals carefully.

The key nutrients and their sources are:

Proteins

Try soy proteins, beans, cereal grains. eggs and milk.

Iron

Try legumes, dry apricots, vitamin C rich products

Increase iron absorption by soaking and sprouting grains

Avoid tannin containing products like tea which interfere with iron absorption

Calcium

Cabbage, broccoli, mustard, turnip

Vitamin D

Almonds

http://t1.gstatic.com/images?q=tbn:ANd9GcSbcwpLLWbCwzgWQjkexLN24ezNOieUjRAcrBmI3EVYWPRxNpnp

ADVISE HER ON HER UNDER NUTRITION STATE AND THE RISK ASSOCIATED WITH GLUTEN FREE PRODUCTS

Being a celiac patient Hafsana has low levels of essential nutrients in her body and now she is going to start gluten free lifestyle.

She should be advised that all the gluten containing foods are also rich source for number of useful nutrients like vitamins,zinc,calcium,magnesium and folic acid and. Thus by removing gluten free foods from her diet can have visible effect on the amount of these nutrients which will cause nutritional deficiencies.

Her nutritional deficiencies can be monitored by routine blood tests upon her follow up appointments .This is also helpful to check that the her intestine has repaired and that the nutrients are being absorbed or not.

Deficiencies of these nutrients will usually correct themselves after a gluten-free diet has been started.This is because the body will start to absorb nutrients more effectively but if however these deficiencies are still there she can take supplements.

For calcium deficiency medications such as bisphosphonates and strontium ranelate may be used as appropriate.

As she is experiencing amenorrhea and mouth ulcers, here zinc supplements are of vital importance for her.

For folic acid deficiencies

Advice her to avoid sunbathing and tanning as it decrease the folic acid content in the body

Also ask her for any medications such as methotrexate,metformin,sulfa drugs which interfere with folic acid absorption.

When cooking, use of steaming or of a food steamer can help keep more folate content in the cooked foods, thus helping to prevent folate deficiency

Tobacco smoking, alcohol consumption decrease folate absorption thus decrease their intake.

SUPPLEMENTS SHE WILL TAKE ARE IN THE FORM OF:

TABLETS/CAPSULES

Multi formula tablets such as celiac/tabs

PARENTERLS

Mostly in emergencies or when oral supplements cannot be tolerated

http://t2.gstatic.com/images?q=tbn:ANd9GcTR2l1aHWW64uoTkJb2dQzUoByYjUvflzqakEiFa6Bzp6G3Xbl07whttp://t3.gstatic.com/images?q=tbn:ANd9GcTKuXGuQP9eI4aaTfC_wDQM6jLwjEUkEmrePpfnVtBIGlSxX4bA

Some multi-nutrients supplements for celiac disease

.http://t0.gstatic.com/images?q=tbn:ANd9GcQpPkvBLJfYTs4Px-ta33XlenvOEYG9IwHr6kVykQVvGQVN3_8Hhttp://t3.gstatic.com/images?q=tbn:ANd9GcRBuVrIGjYA-VB-ksJQhDmmwbrXgb53KSBxQNHxqMzlAefGR4AAhttp://t2.gstatic.com/images?q=tbn:ANd9GcRFVAaElTwHarV7JQnEx4V2KTGkaSi_BpdAwX-yhX7_4Kge0Frq

http://t2.gstatic.com/images?q=tbn:ANd9GcSYe_76qt1-wkCTrjze-7am2m0K7MClkvFhFP5l0gbKYgRTIXcJ2Q

Iron, vitamins and calcium rich foods

PRACTICAL DIETARY ADVICE FOR HAFSANA IF SHE IS WILLING TO GAIN WEIGHT

She can gain a weight of 1lb (0.45kg) per week by consuming 500Kcal of energy for which advise her to choose energy dense foods and to reduce the volume of food.

Examples of such foods are:

Garnish salads with olives, avocadoes,

Gluten-free dressings and cheese.

Dried fruits in syrup instead of fresh fruit 

Try having nuts as a high calorie snack

milky coffee and milk shakes.

Eat small, frequent meals and snacks and try having a snack before bedtime.

ADVISE HAFSANA IF SHE HAS LOW APPETITE

make food look attractive

drink some alcohol before meals to induce appetite

eat meals with company

make mealtimes pleasant

exercise may stimulate appetite.

TREATING HAFSANA’S MOUTH ULCERS

As she is not good at swallowing so try healing ulcers along with gluten free diet

she should maintain oral hygiene

Using mouth washes and regular teeth brushings are helpful in maintaining oral hygiene.

Use medications for her mouth ulcers such as analgesics, anesthetics, antiseptics, anti-inflammatory agents, Debacterol, and silver nitrate. 

Amlexanox paste has been found to speed healing and alleviate pain.

Apply a small amount of table salt directly onto the ulcer for 30 seconds .Although painful but this method is the fastest way to heal a mouth ulcer.

Avoid drinking hot coffees and tea

Avoid spicy foods.

Avoid oily foods

Avoid citrus fruits such as oranges and lemons.

Massage coconut milk on ulcers

Try gargle using tomato juice.

Avoid citrus fruits such as oranges and lemons.

https://healthy.kaiserpermanente.org/static/drugency/images/ACC01000.JPGhttp://t3.gstatic.com/images?q=tbn:ANd9GcT5GX4oh5o0aYbDjTbfftzWtbnxVO0wV7R47XyEfgkSLVGQ1CvSMedications for treating mouth ulcers

ADVICE HAFSANA IF SHE IS WILLING TO HAVE PREGNANCY

First advice her to wave her planning until her celiac disease subsides

If still she want the pregnancy then advise her to:

Stay tuned to gluten free diet

Eat well and include supplements when pregnant

Folic acid intake should be increase up to 5mg/day

Take vitamin D10mcg/day

Take more iron to create body store before pregnancy

Space the food into five parts

Take leafy foods, fibers, meat, beans, dairy products, fruits to meet folic acid and protein requirements

Take starch for energy in the form of potatoes, brown rice.

Drink plenty of water and fiber to avoid constipation in pregnancy.

Gain weight up to 10-14 kg by balance diet.

ADVICE ON FOLLOW UPS

Hafsana shall be advised on her further appointments with her dietician and health care professionals at least annually covering blood tests, bone screening, body mass indices(BMI) .

Asking and accessing the her gluten free lifestyle.

Creating a checklist for accessing relevant parameters.

Solving her complaints about conditions, diet, lifestyle .

FURTHUR COUNSELING POINTS FOR HAFSANA.

If she has a child advice on breast feeding as there is no risk with baby feeding

If she is alcoholic, advise her to check for label.

Go for bulk as it is cheap

Advised to maintain a gluten-free kitchen. A dedicated toaster, bread maker. Other appliances should be obtained for use in preparing gluten-free meals. Utensils and dishes must be carefully cleaned to avoid gluten contamination.

Do not consume citrus fruits as they will worsen and produce pain to mouth ulcers.

Do consider the shelf lives of bulk products.

Help to mix socially with other celiac on face book.

If she is fond of going in parties, gathering do advice her to have a tiff in or carefully eat.

Satisfy her that everything will be fine if she follow this routine.

Pharmacist should be aware of updated list for gluten-free drugs.

PHARMACOLOGICAL MANAGEMENT

At present Hafsana is newly diagnosed celiac patient and can be managed solely by gluten free diet and non- pharmacological interventions.

If however her symptoms will not improve with gluten free diet and she will presents with more severe symptoms such as:

Persistence severe diarrhea

Sudden unexplained weight loss

Abdominal pains

Then she will considered to be a patient of refractory celiac disease and will be treated by medications like

Steroids

Immuno suppresants.

Pain killers can be given to treat mild to moderate pains associated with osteoporosis and mouth ulcers but care should be taken regarding their selection.

Luckily only less than 5% of adult patients are found to have refractory celiac disease which

The immune system of celiac patients is actually overactive and thus the risk of infections arises from hyposplenism, which is common in active celiac disease is higher. Therefore patients especially over 50 years of age are advised to receive pneumococcal vaccine

Annual influenza vaccine is advisable as this will reduce the incidence of secondary bacterial infections.